Are Proud Tibial Cone Constructs an Effective Alternative to Those That are Fully Seated in Revision Total Knee Arthroplasty?

BACKGROUND: This study compared the clinical, radiographic, and patient-reported outcomes between patients treated with the traditional fully seated tibial cone construct and those with the novel proud tibial cone construct in revision total knee arthroplasty (rTKA). METHODS: This was a retrospective study of 56 adult patients who had a minimum 2-year follow-up and underwent rTKA with either the fully seated (n = 18 knees) or proud (n = 42 knees) tibial cone construct between 2010 and 2020. The electronic medical record was reviewed for demographic, clinical, and radiographic data. Knee Injury and Osteoarthritis Outcome Scores (KOOS) were collected. RESULTS: All patients had improved mechanical alignment postoperatively regardless of surgical technique. All patients showed good evidence of osseointegration without loss of fixation at the latest follow-up. There were no significant differences in the complication rate or re-revision rate between the groups. KOOS Function in Sport and Recreation (Sport/Rec) scores were significantly higher for patients treated with the fully seated construct (mean 57 [range, 20 to 95] versus 38 [range, 0 to 75], P = .04); however, no significant differences were present for the other KOOS subscales or KOOS Jr. CONCLUSION: The proud tibial cone construct may be an effective alternative to the fully seated construct in the setting of severe bone loss in rTKA. The proud construct avoids a proximal tibial cut, and thus is a bone-preserving technique that provides good fixation, reduces operative time, prevents potential iatrogenic injuries, decreases the need for tibial augments, saves costs, and improves the ease of restoring joint height.

Did the Physical and Mental Health of Orthopaedic Patients Change After the Onset of the COVID-19 Pandemic?

BACKGROUND: The 2019 novel coronavirus (COVID-19) pandemic has been associated with poor mental health outcomes and widened health disparities in the United States. Given the inter-relationship between psychosocial factors and functional outcomes in orthopaedic surgery, it is important that we understand whether patients presenting for musculoskeletal care during the pandemic were associated with worse physical and mental health than before the pandemic's onset. QUESTIONS/PURPOSES: (1) Did patients seen for an initial visit by an orthopaedic provider during the COVID-19 pandemic demonstrate worse physical function, pain interference, depression, and/or anxiety than patients seen before the pandemic, as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) instrument? (2) During the COVID-19 pandemic, did patients living in areas with high levels of social deprivation demonstrate worse patterns of physical function, pain interference, depression, or anxiety on initial presentation to an orthopaedic provider than patients living in areas with low levels of social deprivation, compared with prepandemic PROMIS scores? METHODS: This was a retrospective, comparative study of new patient evaluations that occurred in the orthopaedic department at a large, urban tertiary care academic medical center. During the study period, PROMIS computer adaptive tests were routinely administered to patients at clinical visits. Between January 1, 2019, and December 31, 2019, we identified 26,989 new patients; we excluded 4% (1038 of 26,989) for being duplicates, 4% (1034 of 26,989) for having incomplete demographic data, 44% (11,925 of 26,989) for not having a nine-digit home ZIP Code recorded, and 5% (1332 of 26,989) for not completing all four PROMIS computer adaptive tests of interest. This left us with 11,660 patients in the "before COVID-19" cohort. Between January 1, 2021 and December 31, 2021, we identified 30,414 new patients; we excluded 5% (1554 of 30,414) for being duplicates, 4% (1142 of 30,414) for having incomplete demographic data, 41% (12,347 of 30,414) for not having a nine-digit home ZIP Code recorded, and 7% (2219 of 30,414) for not completing all four PROMIS computer adaptive tests of interest. This left us with 13,152 patients in the "during COVID-19" cohort. Nine-digit home ZIP Codes were used to determine patients' Area Deprivation Indexes, a neighborhood-level composite measure of social deprivation. To ensure that patients included in the study represented our overall patient population, we performed univariate analyses on available demographic and PROMIS data between patients included in the study and those excluded from the study, which revealed no differences (results not shown). In the before COVID-19 cohort, the mean age was 57 ± 16 years, 60% (7046 of 11,660) were women, 86% (10,079 of 11,660) were White non-Hispanic, and the mean national Area Deprivation Index percentile was 47 ± 25. In the during COVID-19 cohort, the mean age was 57 ± 16 years, 61% (8051 of 13,152) were women, 86% (11,333 of 13,152) were White non-Hispanic, and the mean national Area Deprivation Index percentile was 46 ± 25. The main outcome measures in this study were the PROMIS Physical Function ([PF], version 2.0), Pain Interference ([PI], version 1.1), Depression (version 1.0), and Anxiety (version 1.0). PROMIS scores follow a normal distribution with a mean t-score of 50 and a standard deviation of 10. Higher PROMIS PF scores indicate better self-reported physical capability, whereas higher PROMIS PI, Depression, and Anxiety scores indicate more difficulty managing pain, depression, and anxiety symptoms, respectively. Clinically meaningful differences in PROMIS scores between the cohorts were based on a minimum clinically important difference (MCID) threshold of 4 points. Multivariable linear regression models were created to determine whether presentation to an orthopaedic provider during the pandemic was associated with worse PROMIS scores than for patients who presented before the pandemic. Regression coefficients (ß) represent the estimated difference in PROMIS scores that would be expected for patients who presented during the pandemic compared with patients who presented before the pandemic, after adjusting for confounding variables. Regression coefficients were evaluated in the context of clinical importance and statistical significance. Regression coefficients equal to or greater than the MCID of 4 points were considered clinically important, whereas p values < 0.05 were considered statistically significant. RESULTS: We found no clinically important differences in baseline physical and mental health PROMIS scores between new patients who presented to an orthopaedic provider before the COVID-19 pandemic and those who presented during the COVID-19 pandemic (PROMIS PF: ß -0.2 [95% confidence interval -0.43 to 0.03]; p = 0.09; PROMIS PI: ß 0.06 [95% CI -0.13 to 0.25]; p = 0.57; PROMIS Depression: ß 0.09 [95% CI -0.14 to 0.33]; p = 0.44; PROMIS Anxiety: ß 0.58 [95% CI 0.33 to 0.84]; p < 0.001). Although patients from areas with high levels of social deprivation had worse PROMIS scores than patients from areas with low levels of social deprivation, patients from areas with high levels of social deprivation demonstrated no clinically important differences in PROMIS scores when groups before and during the pandemic were compared (PROMIS PF: ß -0.23 [95% CI -0.80 to 0.33]; p = 0.42; PROMIS PI: ß 0.18 [95% CI -0.31 to 0.67]; p = 0.47; PROMIS Depression: ß 0.42 [95% CI -0.26 to 1.09]; p = 0.23; PROMIS Anxiety: ß 0.84 [95% CI 0.16 to 1.52]; p = 0.02). CONCLUSION: Contrary to studies describing worse physical and mental health since the onset of the COVID-19 pandemic, we found no changes in the health status of orthopaedic patients on initial presentation to their provider. Although large-scale action to mitigate the effects of worsening physical or mental health of orthopaedic patients may not be needed at this time, orthopaedic providers should remain aware of the psychosocial needs of their patients and advocate on behalf of those who may benefit from intervention. Our study is limited in part to patients who had the self-agency to access specialty orthopaedic care, and therefore may underestimate the true changes in the physical or mental health status of all patients with musculoskeletal conditions. Future longitudinal studies evaluating the impact of specific COVID-19-related factors (for example, delays in medical care, social isolation, or financial loss) on orthopaedic outcomes may be helpful to prepare for future pandemics or natural disasters. LEVEL OF EVIDENCE: Level II, prognostic study.

Outcomes following surgical treatment of distal radial fracture: a comparison of older and younger patients using PROMIS.

The purpose of this study was to assess the recovery patterns following surgery for distal radial fracture (DRF) in patients over (n = 99) and under (n = 273) the age of 65 using the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) questionnaires. Both the older and younger cohorts showed postoperative improvement in PF and PI. The younger cohort had higher PF scores from 1 to 6 months postoperatively, however, PI scores were not significantly different between the cohorts during any period. A greater proportion of younger patients achieved the minimal clinically important difference improvement on the PROMIS PF (80% versus 66%) and PI (88% versus 75%) scales. To appropriately manage postoperative expectations, older patients should be counselled that they would likely experience most of their functional recovery by 3 months and limitations due to pain would likely be stable by 1 month.Level of evidence: II.

Minimal Clinically Important Difference for PROMIS Physical Function and Pain Interference in Patients Following Surgical Treatment of Distal Radius Fracture.

PURPOSE: We estimated the minimal clinically important difference (MCID) for the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) computer adaptive tests (CATs) following surgical treatment of distal radius fracture (DRF). METHODS: Adult patients surgically treated between November 2017 and November 2020 for isolated DRF were identified. Demographic and patient-reported outcome data were extracted from the electronic health record. Outcomes of interest were the PROMIS PF and PI CATs. Inclusion criteria were met if: (1) PROMIS PF and PI scores were available at preoperative and postoperative visits; and (2) a postoperative clinical anchor question asking about overall response to treatment was answered. An anchor-based MCID estimate was determined by calculating the average absolute score change in PROMIS PF and PI for patients who indicated a mild change to the anchor question. A distribution-based MCID estimate was also calculated using the standard error of measurement and effect sizes of change. RESULTS: The changes in PROMIS PF and PI scores were significantly different between patients who gave responses of much change (n = 73), mild change (n = 51), and no change (n = 19) to the clinical anchor question. The average score changes in the mild change group for PROMIS PF and PI were 5.2 (SD, 3.7) and 6.8 (SD, 4.3) points, respectively, representing the anchor-based MCID estimates. The PROMIS PI anchor-based estimate was moderately correlated with the preoperative score (r = -0.41), time between visits (r = -0.39), and age (r = 0.30). The distribution-based MCID estimates were 3.8 (SD, 1.3) and 3.7 (SD, 1.3) points for the PROMIS PF and PI, respectively. CONCLUSIONS: The MCIDs were estimated as 5.2 and 6.8 for the PROMIS PF and PI CATs, respectively, following surgery for DRF. CLINICAL RELEVANCE: As reports continue to publish a consistent range of MCID values, researchers can be confident in these values and begin using them across a broader spectrum of conditions treated by hand surgeons.

Electromagnetic stimulation increases mitochondrial function in osteogenic cells and promotes bone fracture repair.

Bone fracture is a growing public health burden and there is a clinical need for non-invasive therapies to aid in the fracture healing process. Previous studies have demonstrated the utility of electromagnetic (EM) fields in promoting bone repair; however, its underlying mechanism of action is unclear. Interestingly, there is a growing body of literature describing positive effects of an EM field on mitochondria. In our own work, we have previously demonstrated that differentiation of osteoprogenitors into osteoblasts involves activation of mitochondrial oxidative phosphorylation (OxPhos). Therefore, it was reasonable to propose that EM field therapy exerts bone anabolic effects via stimulation of mitochondrial OxPhos. In this study, we show that application of a low intensity constant EM field source on osteogenic cells in vitro resulted in increased mitochondrial membrane potential and respiratory complex I activity and induced osteogenic differentiation. In the presence of mitochondrial inhibitor antimycin A, the osteoinductive effect was reversed, confirming that this effect was mediated via increased OxPhos activity. Using a mouse tibial bone fracture model in vivo, we show that application of a low intensity constant EM field source enhanced fracture repair via improved biomechanical properties and increased callus bone mineralization. Overall, this study provides supporting evidence that EM field therapy promotes bone fracture repair through mitochondrial OxPhos activation.

Ability of Medial Patellofemoral Ligament Reconstruction to Overcome Lateral Patellar Motion in the Presence of Trochlear Flattening: A Cadaveric Biomechanical Study.

BACKGROUND: Medial patellofemoral ligament (MPFL) reconstruction is an established operative procedure to restore medial restraining force in patients with patellar instability. In the setting of a shallow sulcus, it is unclear whether an isolated MPFL reconstruction is sufficient to restore patellofemoral stability. HYPOTHESIS: Progressively increasing the sulcus angle would have an adverse effect on the ability of an MPFL reconstruction to restrain lateral patellar motion. STUDY DESIGN: Controlled laboratory study. METHODS: Seven fresh-frozen human cadaveric knees were harvested and prepared for experimentation. Each specimen was run through the following test conditions: native, lateral retinacular release, lateral retinacular repair, MPFL release, MPFL reconstruction, and MPFL reconstruction with trochlear flattening. Four 3-dimensional printed wedges (10°, 20°, 30°, and 40°) were created to insert beneath the native trochlea to raise the sulcus angle incrementally and simulate progressive trochlear flattening. For each test condition, the knee was positioned at 0°, 15°, 30°, and 45° of flexion, and the force required to displace the patella 1 cm laterally at 10 mm/s was measured. Group comparisons were made with repeated measures analysis of variance. RESULTS: In the setting of an MPFL reconstruction, as the trochlear groove was incrementally flattened, the force required to laterally displace the patella progressively decreased. A 10° increase in the sulcus angle significantly reduced the force at 15° (P = .01) and 30° (P = .03) of knee flexion. The force required to laterally displace the patella was also significantly lower at all knee flexion angles after the addition of the 20°, 30°, and 40° wedges (P≤ .05). Specifically, a 20° increase in the sulcus angle reduced the force by 29% to 36%; a 30° increase, by 35% to 43%; and a 40° increase, by 40% to 47%. CONCLUSION: Despite an MPFL reconstruction, the force required to laterally displace the patella decreased as the sulcus angle was increased in our cadaveric model. CLINICAL RELEVANCE: An isolated MPFL reconstruction may not be sufficient to restore patellar stability in the setting of a shallow or flat trochlea. Patients with an abnormal sulcus angle may have recurrent instability postoperatively if treated with an isolated MPFL reconstruction.

Bone morphogenic protein-2 signaling in human disc degeneration and correlation to the Pfirrmann MRI grading system.

BACKGROUND CONTEXT: Back and neck pain secondary to disc degeneration is a major public health burden. There is a need for therapeutic treatments to restore intervertebral disc (IVD) composition and function. PURPOSE: To quantify ALK3, BMP-2, pSMAD1/5/8 and MMP-13 expression in IVD specimens collected from patients undergoing surgery for disc degeneration, to correlate ALK3, BMP-2, pSMAD1/5/8 and MMP-13 expression in IVD specimens to the 5-level Pfirrmann MRI grading system, and to compare ALK3, BMP-2, pSMAD1/5/8 and MMP-13 expression between cervical and lumbar degenerative disc specimens. STUDY DESIGN: An immunohistochemical study assessing ALK3, BMP-2, pSMAD1/5/8, and MMP-13 expression levels in human control and degenerative IVD specimens. METHODS: Human IVD specimens were collected from surgical patients who underwent discectomy and interbody fusion at our institution between 1/2015 and 8/2017. Each patient underwent MRI prior to surgery. The degree of disc degeneration was measured according to the 5-level Pfirrmann MRI grading system. Patients were categorized into either the 1) control group (Pfirrmann grades I-II) or 2) degenerative group (Pfirrmann grades III-V). Histology slides of the collected IVD specimens were prepared and immunohistochemical staining was performed to assess ALK3, BMP-2, pSMAD1/5/8, and MMP-13 expression levels in the control and degenerative specimens. Expression levels were also correlated to the Pfirrmann criteria. Lastly, the degenerative specimens were stratified according to their vertebral level and expression levels between the degenerative lumbar and cervical discs were compared. RESULTS: Fifty-two patients were enrolled; however, 2 control and 2 degenerative patients were excluded due to incomplete data sets. Of the remaining 48 patients, there were 12 control and 36 degenerative specimens. Degenerative specimens had increased expression levels of BMP-2 (p=.0006) and pSMAD1/5/8 (p<.0001). Pfirrmann grade 3 (p=.0365) and grade 4 (p=.0008) discs had significantly higher BMP-2 expression as compared to grade 2 discs. Pfirrmann grade 4 discs had higher pSMAD1/5/8 expression as compared to grade 2 discs (p<.0001). There were no differences in ALK3 or MMP-13 expression between the control and degenerative discs (p>.05). Stratifying the degenerative specimens according to their vertebral level showed no significant differences in expression levels between the lumbar and cervical discs (p>.05). CONCLUSIONS: BMP-2 and pSMAD1/5/8 signaling activity was significantly upregulated in the human degenerative specimens, while ALK3 and MMP-13 expression were not significantly changed. The expression levels of BMP-2 and pSMAD1/5/8 correlate positively with the degree of disc degeneration measured according to the Pfirrmann MRI grading system. CLINICAL SIGNIFICANCE: BMP-SMAD signaling represents a promising therapeutic target to restore IVD composition and function in the setting of disc degeneration.

Role of oxidative metabolism in osseointegration during spinal fusion.

Spinal fusion is a commonly performed orthopedic surgery. Autologous bone graft obtained from the iliac crest is frequently employed to perform spinal fusion. Osteogenic bone marrow stromal (a.k.a. mesenchymal stem) cells (BMSCs) are believed to be responsible for new bone formation and development of the bridging bone during spinal fusion, as these cells are located in both the graft and at the site of fusion. Our previous work revealed the importance of mitochondrial oxidative metabolism in osteogenic differentiation of BMSCs. Our objective here was to determine the impact of BMSC oxidative metabolism on osseointegration of the graft during spinal fusion. The first part of the study was focused on correlating oxidative metabolism in bone graft BMSCs to radiographic outcomes of spinal fusion in human patients. The second part of the study was focused on mechanistically proving the role of BMSC oxidative metabolism in osseointegration during spinal fusion using a genetic mouse model. Patients' iliac crest-derived graft BMSCs were identified by surface markers. Mitochondrial oxidative function was detected in BMSCs with the potentiometric probe, CMXRos. Spinal fusion radiographic outcomes, determined by the Lenke grade, were correlated to CMXRos signal in BMSCs. A genetic model of high oxidative metabolism, cyclophilin D knockout (CypD KO), was used to perform spinal fusion in mice. Graft osseointegration in mice was assessed with micro-computed tomography. Our study revealed that higher CMXRos signal in patients' BMSCs correlated with a higher Lenke grade. Mice with higher oxidative metabolism (CypD KO) had greater mineralization of the spinal fusion bridge, as compared to the control mice. We therefore conclude that higher oxidative metabolism in BMSCs correlates with better spinal fusion outcomes in both human patients and in a mouse model. Altogether, our study suggests that promoting oxidative metabolism in osteogenic cells could improve spinal fusion outcomes for patients.

Ossification of the Posterior Longitudinal Ligament in North American Patients: Does Presentation with Spinal Cord Injury Matter?

OBJECTIVE: We sought to evaluate the influence of trauma-induced spinal cord injury (SCI) on the operative management of cervical ossification of the posterior longitudinal ligament (OPLL) in a North American cohort. METHODS: A retrospective chart review was performed for all patients who underwent surgical management for OPLL in an academic medical center between November 2006 and July 2019. Patients were categorized into 1 of 2 groups and compared on the basis of their initial presentation: 1) SCI with OPLL or 2) cervical myelopathy (CM) with OPLL. Patient characteristics were collected. OPLL classification and K-line measurements were performed. Surgical approach, levels fused/decompressed, blood loss, postoperative length of stay, surgical complications, and neurologic outcome were recorded. RESULTS: Among the 28-patient cohort, 12 were in the SCI with OPLL group and 16 were in the CM with OPLL group. The most common type of OPLL in both groups was segmental (n = 21, 75%). The average levels fused/decompressed (P = 0.0176), estimated blood loss (P = 0.0204), and postoperative length of stay (P = 0.0003) were all significantly higher in the SCI with OPLL group. There were significantly more anterior-only surgical approaches performed in the CM with OPLL group (P = 0.0159). The motor score at admission (P = 0.0005) and at latest follow-up (P = 0.0003) for the SCI with OPLL group was significantly lower than the CM with OPLL group. CONCLUSIONS: Patients with SCI complicated by OPLL had worse preoperative and postoperative neurologic motor scores as compared with patients in the CM with OPLL group. Most of the patients in our cohort showed neurologic improvement.

Lactate Dehydrogenase Inhibition With Oxamate Exerts Bone Anabolic Effect.

Cellular bioenergetics is a promising new therapeutic target in aging, cancer, and diabetes because these pathologies are characterized by a shift from oxidative to glycolytic metabolism. We have previously reported such glycolytic shift in aged bone as a major contributor to bone loss in mice. We and others also showed the importance of oxidative phosphorylation (OxPhos) for osteoblast differentiation. It is therefore reasonable to propose that stimulation of OxPhos will have bone anabolic effect. One strategy widely used in cancer research to stimulate OxPhos is inhibition of glycolysis. In this work, we aimed to evaluate the safety and efficacy of pharmacological inhibition of glycolysis to stimulate OxPhos and promote osteoblast bone-forming function and bone anabolism. We tested a range of glycolytic inhibitors including 2-deoxyglucose, dichloroacetate, 3-bromopyruvate, and oxamate. Of all the studied inhibitors, only a lactate dehydrogenase (LDH) inhibitor, oxamate, did not show any toxicity in either undifferentiated osteoprogenitors or osteoinduced cells in vitro. Oxamate stimulated both OxPhos and osteoblast differentiation in osteoprogenitors. In vivo, oxamate improved bone mineral density, cortical bone architecture, and bone biomechanical strength in both young and aged C57BL/6J male mice. Oxamate also increased bone formation by osteoblasts without affecting bone resorption. In sum, our work provided a proof of concept for the use of anti-glycolytic strategies in bone and identified a small molecule LDH inhibitor, oxamate, as a safe and efficient bone anabolic agent. © 2020 American Society for Bone and Mineral Research (ASBMR).

Trends and Characteristics of Spine Research From 2006 to 2015: A Review of Spine Articles in a High Impact General Orthopedic Journal.

STUDY DESIGN: Literature review. OBJECTIVE: To determine characteristics and trends in published spine research over a recent decade in a high impact, general orthopedic surgery journal. SUMMARY OF BACKGROUND DATA: Recent trends in published spine research in a high-impact orthopedic surgery journal are unknown. Such knowledge could guide future research in the field. METHODS: A comprehensive literature review of clinical and basic science spine articles published in The Journal of Bone & Joint Surgery from 2006 to 2015 was conducted. Articles were assessed for: title, year of publication, authorship, academic degrees of the authors, number of citations, institution of origin, and spine topic. Clinical articles were evaluated for: sex and race/ethnicity of the human subjects, level of evidence, and inclusion of patient-reported outcome measures (PROMs). Basic science articles were evaluated for: type of study (animal, cadaver, cell-based), sex of the animals, cadavers or cells studied (male, female, or male and female), and presence of sex-based reporting (defined as reporting of results by sex). RESULTS: A total of 203 spine articles were evaluated from the 10-year study period. At least 35 validated or nonvalidated patient-reported outcome measures were utilized in clinical spine research. The most commonly reported PROMs were the Oswestry Disability Index (24.4%), Short Form-36 Health Survey (23.7%), and Visual Analog Scale for Pain (19.3%). The average level of evidence improved from 3.25 in 2006 to 2.60 in 2015. Only 13.2% of clinical spine articles reported the race/ethnicity of the subjects. CONCLUSION: A consensus regarding validated PROMs in spine research would be valuable. From 2006 to 2015, the level of evidence of spine articles in The Journal of Bone & Joint Surgery improved. Accurate and complete reporting of patient demographics is an area for improvement in spine research in light of studies demonstrating sex and race/ethnicity-related differences in clinical outcome after spine surgery. LEVEL OF EVIDENCE: 5.

Publication rate of podium presentations from the orthopaedic research society annual meeting.

Annual scientific meetings serve as a forum for dissemination of new research findings. Presentations should be of high scientific quality as they have the potential to impact future research projects and current clinical practice. The publication rate of podium presentations at an annual meeting can be used to assess the quality of the research presented. The purpose of this study was to determine the publication rate of podium presentations at the Orthopaedic Research Society (ORS) annual meeting. All podium presentations from the 2012 to 2014 annual ORS meetings were identified. Abstracts were categorized into an orthopaedic topic. A PubMed search was performed to determine if an abstract reached publication in a peer-reviewed journal. The publication rate was determined for each year. Of the 1063 podium presentations identified, 640 (60.2%) reached publication in a peer-reviewed journal. No significant differences were observed in the publication rate between the orthopaedic topics (p = 0.3414). The majority (75.9%) of published abstracts reached publication within 2 years of presentation and the average time to publication was 17.0 months. Abstracts were published in 151 different journals with an average impact factor of 4.46. Time to publication varied significantly by journal (p = 0.025). Journal of Orthopaedic Research, Journal of Biomechanics, PLoS ONE, Osteoarthritis and Cartilage, and Bone were the most common publication journals. This study provides insight into the quality of podium presentations at the ORS annual meeting. The ORS annual meeting compares favorably to other orthopaedic surgery meetings. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:288-292, 2019.

Rupture of Giant Anterior Sacral Meningocele in a Patient with Marfan Syndrome: Diagnosis and Management.

BACKGROUND: Marfan syndrome is a genetic disorder that results in the weakening of connective tissues. Dural ectasia has been defined as a feature of Marfan syndrome and is present in up to 92% of patients. Rarely, dural ectasia can erode through the sacrum expanding into an anterior sacral meningocele. CASE DESCRIPTION: Information for this case report was gathered from patient notes and imaging from the patient chart. This is a case of a 46-year-old woman who presented with urinary incontinence, early satiety, and back pain in the setting of a known anterior sacral meningocele. Before operative management, the anterior sacral meningocele ruptured with the patient presenting signs and symptoms of intracranial hypotension. Conservative management did not alleviate the pain. She was ultimately managed with posterior sacroplasty followed by anterior sacral meningocele resection and placement of a lumboperitoneal shunt. The patient did not have reaccumulation of the meningocele or recurrent symptoms at the latest follow-up. CONCLUSIONS: The progression of dural ectasia in Marfan syndrome to an anterior sacral meningocele is uncommon. It is important to identify the characteristics associated with an expanding dural ectasia as this patient's symptoms progressed over time and the meningocele grew large. Given its rarity, there are no guidelines in place regarding size at which repair of an anterior sacral meningocele should occur prophylactically. It is important to review these cases in order continue to learn about progression, management, and outcomes of patients with an anterior sacral meningocele.